<%@ Page Title="" Language="vb" AutoEventWireup="false" MasterPageFile="~/Membership.Master"
    CodeBehind="ApplicationForm.aspx.vb" Inherits="NENAMembership.ApplicationForm" %>

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<asp:Content ID="Content1" ContentPlaceHolderID="head" runat="server">
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="ContentPlaceHolder1" runat="server">
    <div class="container1">
        <div class="container1-top">
        </div>
        <div class="container1-bg">
            <table cellpadding="0" cellspacing="0">
                <tr>
                    <td width="64%" height="135" valign="top" bgcolor="#e0e0e0" style="padding: 10px;">
                        <p>
                            &nbsp;</p>
                        <p>
                            <span class="blog-heading">Application for NENA Membership</span></p>
                        <p>
                            &nbsp;</p>
                        <ul>
                            <li><strong>Please complete the following form to apply for NENA membership.</strong>
                            </li>
                            <li><strong>All fields with a <font color="red">*</font> are Required</strong> </li>
                            <li>Please <b>Do Not</b> use Apostrophes or special characters. They will be removed
                                from your application form (@ is&nbsp;allowed for email only). </li>
                            <li>Once completed, click SUBMIT at the bottom of the page.<br />
                                Your application will be sent to the appropriate NENA representative. </li>
                            <li>Fees vary between NENA affiliates.<br />
                                Once you select an affiliate you will be notified of the fee, and who to send the
                                fee to. </li>
                            <li>
                                <p>
                                    You will be notified by EMAIL once your application has been accepted.<br />
                                    Your membership will give you membership access to the NENA website.
                                </p>
                            </li>
                        </ul>
                    </td>
                    <td width="36%" height="135" align="right" bgcolor="#e0e0e0">
                        <asp:Image ID="Image2" runat="server" ImageUrl="http://images.nena.ca/nena/oldNENAleaf.png"
                            AlternateText="NENA Logo"></asp:Image>
                    </td>
                </tr>
            </table>
            <br />
            <table id="ApplicationForm" width="100%">
                <tr>
                    <td>
                    </td>
                    <td colspan="2">
                        <asp:ValidationSummary ID="ValidationSummary2" runat="server" HeaderText="Please Complete all the Required Fields Below">
                        </asp:ValidationSummary>
                    </td>
                </tr>
                <tr class="DataGridHeader">
                    <td colspan="3">
                        Personal Information
                    </td>
                </tr>
                <tr>
                    <td>
                        First Name:
                    </td>
                    <td colspan="2">
                        <asp:TextBox ID="PersonalFirstName" runat="server" Width="200"></asp:TextBox><strong><font
                            color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="RequiredFieldValidator1" runat="server" ControlToValidate="PersonalFirstName"
                            ErrorMessage="First Name is Required">Required</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Last Name:
                    </td>
                    <td colspan="2">
                        <asp:TextBox ID="PersonalLastName" runat="server" Width="200"></asp:TextBox><strong><font
                            color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="RequiredFieldValidator2" runat="server" ControlToValidate="PersonalLastName"
                            ErrorMessage="Last Name is Required">Required</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Email Address:
                    </td>
                    <td colspan="2">
                        <ew:MaskedTextBox ID="PersonalEmail" runat="server" ErrorMessage="Please Enter a Valid Email Address"
                            ValidationExpression=".*@.*." Validate="True" Width="150" Enabled="False">
                        </ew:MaskedTextBox>
                        &nbsp;<font size="2"><strong>Filled from the disclaimer page</strong></font>
                    </td>
                </tr>
                <tr>
                    <td>
                        Home Phone:
                    </td>
                    <td colspan="2">
                        <ew:MaskedTextBox ID="PersonalHomePhone" runat="server" Width="88px" ErrorMessage="Please use the Noted Format"
                            ValidationExpression="^\d{3}-\d{3}-\d{4}$" Validate="True" AutoFillMask="True"
                            Mask="999-999-9999">
                        </ew:MaskedTextBox>
                        <strong><font color="red">*</font></strong> <em>555-555-5555 format</em>
                        <asp:RequiredFieldValidator ID="Requiredfieldvalidator7" runat="server" ControlToValidate="PersonalHomePhone"
                            ErrorMessage="Home Phone is Required">Required</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Address:
                    </td>
                    <td colspan="2">
                        <asp:TextBox ID="PersonalAddress1" runat="server" Width="264px"></asp:TextBox><strong>
                            <font color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="RequiredFieldValidator3" runat="server" ControlToValidate="PersonalAddress1"
                            ErrorMessage="Address is Required">Required</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Additional Address Info:
                    </td>
                    <td>
                        <asp:TextBox ID="PersonalAddress2" runat="server" Width="264px"></asp:TextBox>
                    </td>
                </tr>
                <tr>
                    <td colspan="2">
                        City:
                        <asp:TextBox ID="PersonalCity" runat="server" Width="150px"></asp:TextBox><strong><font
                            color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="RequiredFieldValidator4" runat="server" ControlToValidate="PersonalCity"
                            ErrorMessage="City is Required">Required</asp:RequiredFieldValidator>
                    </td>
                    <td>
                        Postal Code:
                        <asp:TextBox ID="PersonalPostalCode" runat="server" Width="80px"></asp:TextBox><strong><font
                            color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="RequiredFieldValidator5" runat="server" ControlToValidate="PersonalPostalCode"
                            ErrorMessage="Postal Code is Required">Required</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td colspan="3">
                        Province:
                        <asp:DropDownList ID="ddlPersonalProvince" runat="server" Width="160px" AutoPostBack="True"
                            OnSelectedIndexChanged="SetAffiliate" />
                        <strong><font color="red">*</font></strong>
                        <asp:RangeValidator ID="RangeValidator1" runat="server" ControlToValidate="ddlPersonalProvince"
                            ErrorMessage="Province Is Required" Type="Integer" MinimumValue="1" MaximumValue="14">Required, Select International for Outside of Canada including USA</asp:RangeValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        <asp:Label ID="lblOtherState" runat="server" Visible="False">State: </asp:Label>
                        <asp:TextBox ID="txtOtherState" runat="server" Visible="False"></asp:TextBox>
                    </td>
                    <td>
                        <asp:Label ID="lblOtherCountry" runat="server" Visible="False">Country: </asp:Label>
                        <asp:TextBox ID="txtOtherCountry" runat="server" Visible="False"></asp:TextBox>
                    </td>
                </tr>
                <tr>
                    <td colspan="3">
                        <asp:ScriptManager ID="ScriptManager1" runat="server" />
                        <asp:UpdatePanel ID="UpdatePanel1" runat="server" ChildrenAsTriggers="False" UpdateMode="Conditional">
                            <ContentTemplate>
                                <asp:TextBox ID="txtInternational" runat="server" BackColor="Yellow" Font-Bold="True"
                                    Visible="false" Width="700px"></asp:TextBox><br />
                                <asp:Label ID="lblAffiliate" runat="server" Visible="False">Choose an Affiliate: </asp:Label>
                                <asp:DropDownList ID="ddlAffiliate" runat="server" Width="208px" OnSelectedIndexChanged="SetFee"
                                    Visible="False" />
                                &nbsp;
                                <asp:Label ID="lblFee" runat="server" Visible="False"></asp:Label>
                                <asp:TextBox ID="txtProvinceID" runat="server" Width="32px" Visible="False"></asp:TextBox>
                                <asp:TextBox ID="txtAffiliateID" runat="server" Width="32px" Visible="False"></asp:TextBox><br />
                                <asp:Label ID="lbl_ENAODistricts" runat="server" Visible="False">ENAO District:</asp:Label>&nbsp;
                                <asp:DropDownList ID="ddl_ENAODistricts" runat="server" Visible="False">
                                </asp:DropDownList>
                                <asp:RangeValidator ID="rv_ENAODistricts" runat="server" ControlToValidate="ddl_ENAODistricts"
                                    ErrorMessage="ENAO District Required" Type="Integer" MinimumValue="1" MaximumValue="12"
                                    Visible="False">*Required, Select unknown if unsure of your District</asp:RangeValidator><br />
                                <asp:CheckBox ID="check_RNAO" runat="server" Visible="False" Text="RNAO Member? (check for yes, unchecked for no)">
                                </asp:CheckBox>
                            </ContentTemplate>
                            <Triggers>
                                <asp:AsyncPostBackTrigger ControlID="ddlPersonalProvince" EventName="SelectedIndexChanged" />
                                <asp:AsyncPostBackTrigger ControlID="ddlAffiliate" EventName="SelectedIndexChanged" />
                            </Triggers>
                        </asp:UpdatePanel>
                    </td>
                </tr>
                <tr>
                    <td>
                    </td>
                </tr>
                <tr class="DataGridHeader">
                    <td colspan="3">
                        Professional Information
                    </td>
                </tr>
            </table>
            <table id="InstructionInformation" width="100%">
                <tr>
                    <td width="30%">
                    </td>
                    <td width="40%">
                    </td>
                    <td width="30%">
                    </td>
                </tr>
                <tr>
                    <td>
                        ENC(C) Emergency Nursing Certified Canada:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkENCCCertified" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Current TNCC Course Director:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkTNCCDirector" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Current TNCC Instructor:
                    </td>
                    <td colspan="2">
                        <asp:CheckBox ID="chkTNCCInstructor" runat="server" AutoPostBack="True"></asp:CheckBox>&nbsp;
                        <asp:Label ID="lblTNCCID" runat="server" Visible="False">TNCC ID:</asp:Label>
                        <asp:TextBox ID="txtTNCCID" runat="server" Width="83px" Visible="False"></asp:TextBox>
                        <asp:RequiredFieldValidator ID="validateTNCCID" runat="server" ControlToValidate="txtTNCCID"
                            ErrorMessage="TNCC ID Required for Instructor" Enabled="False" Visible="False">* Required: Type NEW if unassigned</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Current ENPC Course Director:
                    </td>
                    <td colspan="2">
                        <asp:CheckBox ID="chkENPCDirector" runat="server"></asp:CheckBox>&nbsp;
                    </td>
                </tr>
                <tr>
                    <td>
                        Current ENPC Instructor:
                    </td>
                    <td colspan="2">
                        <asp:CheckBox ID="chkENPCInstructor" runat="server" AutoPostBack="True"></asp:CheckBox>
                        &nbsp;
                        <asp:Label ID="lblENPCID" runat="server" Visible="False">ENPC ID:</asp:Label>
                        <asp:TextBox ID="txtENPCID" runat="server" Width="88px" Visible="False"></asp:TextBox>
                        <asp:RequiredFieldValidator ID="ValidateENPCID" runat="server" ControlToValidate="txtENPCID"
                            ErrorMessage="ENPC ID Required for Instructor" Enabled="False" Visible="False">* Required: Type NEW if unassigned</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Current CATN Course Director:
                    </td>
                    <td colspan="2">
                        <asp:CheckBox ID="chkCATNDirector" runat="server"></asp:CheckBox>&nbsp;
                        <asp:Label ID="lblCATNID" runat="server" Visible="False">CATN ID:</asp:Label>
                        <asp:TextBox ID="txtCATNID" runat="server" Width="88px" Visible="False"></asp:TextBox>
                        <asp:RequiredFieldValidator ID="validateCATNID" runat="server" ControlToValidate="txtCATNID"
                            ErrorMessage="CATN ID Required for Instructor" Enabled="False" Visible="False">* Required: Type NEW if unassigned</asp:RequiredFieldValidator>
                    </td>
                </tr>
            </table>
            <asp:Panel ID="panelInstructorTrainer" runat="server" Visible="false">
                <table id="tblInstructorTrainer" width="100%">
                    <tr>
                        <td>
                            Current P-CTAS Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkPCTASProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current P-CTAS Instructor:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkPCTASInstructor" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current P-CTAS Instructor Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkPCTASTrainer" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current P-CTAS Course Director:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkPCTASDirector" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current A-CTAS Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkACTASProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current A-CTAS Instructor:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkACTASInstructor" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current A-CTAS Instructor Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkACTASTrainer" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current A-CTAS Course Director:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkACTASDirector" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current C-CTAS Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkCCTASTrainer" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current C-CTAS Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkCCTASProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current ENPC Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkENPCProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current ENPC Instructor Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkENPCTrainer" runat="server"></asp:CheckBox>&nbsp;
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current CATN Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkCATNProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current CATN Instructor:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkCATNInstructor" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current CATN Instructor Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkCATNTrainer" runat="server"></asp:CheckBox>&nbsp;
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current TNCC Provider:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkTNCCProvider" runat="server"></asp:CheckBox>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Current TNCC Instructor Trainer:
                        </td>
                        <td>
                            <asp:CheckBox ID="chkTNCCTrainer" runat="server"></asp:CheckBox>&nbsp;
                        </td>
                    </tr>
                </table>
            </asp:Panel>
            <table id="ApplicationForm2" width="100%">
                <tr>
                    <td width="30%">
                    </td>
                    <td width="40%">
                    </td>
                    <td width="30%">
                    </td>
                </tr>
                <tr class="DataGridHeader">
                    <td style="height: 17px" colspan="3">
                        Area of Employment - Please Select All that Apply
                    </td>
                </tr>
                <tr>
                    <td>
                        Administration:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkEmployeeAdministration" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Clinical:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkEmployeeClinical" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Educator:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkEmployeeEducator" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Research:
                    </td>
                    <td>
                        <asp:CheckBox ID="chkEmployeeResearch" runat="server"></asp:CheckBox>
                    </td>
                </tr>
                <tr>
                    <td>
                        Work Phone:
                    </td>
                    <td colspan="2">
                        <ew:MaskedTextBox ID="txtWorkPhone" runat="server" Width="130px" ErrorMessage="Please use the Noted Format"
                            ValidationExpression="^\d{3}-\d{3}-\d{4}$" Validate="True" AutoFillMask="True"
                            Mask="999-999-9999">
                        </ew:MaskedTextBox>
                        <em>555-555-5555 format</em>
                    </td>
                </tr>
                <tr>
                    <td>
                        Nurses License ID:
                    </td>
                    <td colspan="2">
                        <asp:TextBox ID="txtNursesLicenseID" runat="server" Width="131px"></asp:TextBox><strong><font
                            color="red">*</font></strong>
                        <asp:RequiredFieldValidator ID="Requiredfieldvalidator8" runat="server" ControlToValidate="txtNursesLicenseID"
                            ErrorMessage="License ID is Required <br/> Type 'New' if you have not recieved your License number">License ID is Required <br/> Type 'New' if you have not recieved your License number</asp:RequiredFieldValidator>
                    </td>
                </tr>
                <tr>
                    <td>
                        Employer:
                    </td>
                    <td colspan="2">
                        <asp:TextBox ID="txtEmployer" runat="server"></asp:TextBox>
                    </td>
                </tr>
                <tr>
                    <td colspan="3">
                        <hr />
                    </td>
                </tr>
                <tr>
                    <td>
                    </td>
                    <td colspan="2">
                        <asp:ValidationSummary ID="ValidationSummary1" runat="server" HeaderText="Please Complete all the Required Fields Above">
                        </asp:ValidationSummary>
                    </td>
                </tr>
                <tr>
                    <td colspan="3">
                        <hr />
                    </td>
                </tr>
                <tr align="center">
                    <td>
                        <input id="BtnCancel" type="button" value="Cancel" name="BtnCancel" runat="server"
                            onserverclick="BtnCancel_ServerClick" />
                    </td>
                    <td>
                        <asp:Button ID="BtnSave" runat="server" Text="Submit"></asp:Button>
                    </td>
                </tr>
            </table>
        </div>
        <div class="container1-bottom">
        </div>
    </div>
</asp:Content>
